Pinnacle Park Nursing & Rehab Center

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 3 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside. Findings included: -R3's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body) and a need for assistance with personal care. R3' s Quarterly Minimum Data Set dated 05/23/26, documented R3 had intact cognition, functional range of motion impairment on one side of the upper and lower extremities, and was dependent on staff for dressing, personal and toileting hygiene, transfers, and bed mobility. R3 was frequently incontinent of urine and bowel. R3's Care Plan dated 06/08/26, documented R3 needed assistance with activities of daily living related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure Resident (R) 7 had an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing). Findings included:- R7's Medical Diagnosis tab of the Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent injury when a Certified Nurse Aide (CNA) provided footcare to Resident (R) 13, who had a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and received a cut to her left great toe. Findings included:- The Electronic Medical Record (EMR) documented R13 had a diagnosis of type 2 DM.R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition. She was dependent upon staff for toileting, lower body dressing, putting on her shoes, mobility, and transfers. It was documented R13 received insulin daily.R13's Quarterly MDS, dated 04/29/2026, documented that R13 had intact cognition. She was dependent upon staff assistance for toileting, showers, lower-body dressing, mobility, and did not ambulate. It was documented R13 received insulin daily.R13's 06/09/2026 Care Plan had interventions dated 09/16/2020, that instructed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to hold blood pressure medication, per the physician-ordered parameters, for Resident (R) 13. Findings included:- R13's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type 2.The Annual Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition. R13 was dependent upon staff assistance for toileting, transfers, and lower-body dressing. R13 required substantial staff assistance with showers, personal hygiene, and upper body dressing.The Quarterly MDS, dated 04/29/26, documented that R13 had intact cognition. R13 was dependent upon staff assistance for toileting, showers, lower-body dressing, mobility, and did not ambulate.R13's 06/09/2026 Care Plan included the following interventions for R13:10/05/2020-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 56 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) were reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA 0, hired on 08/27/21, had no yearly performance evaluations upon request. CNA P, hired on 08/04/20, had no yearly performance evaluations upon request. CNA Q, hired on 12/12/22, had no yearly performance evaluations upon request. CNA R, hired on 02/21/22, had no yearly performance evaluations upon request. CNA S, hired on 05/27/23, had no yearly performance evaluations upon request. On 07/23/24 at 04:04 PM, Administrative Nurse D stated the facility was not currently up to date on performance evaluations for CNAs and said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 56 residents. The facility identified two residents on contact-based precautions and six on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, hand hygiene, storage of oxygen tubing while not in use, and disinfecting of shared equipment. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 07/22/24 at 08:00 AM an electric razor with brown shavings was laid on an EBP cart outside of Resident (R)22's room. The soiled razor was not in a container. On 07/22/24 at 08:10 AM, Certified Nursing Aide (CNA) M pushed the Hoyer (total body mechanical lift) from Resident (R)22's room into R49's room without sanitizing the Hoyer lift. CNA M did not perform hand hygiene upon leaving R22's room and before entering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 56 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise Resident (R)5's Care Plan to reflect her Hoyer lift (total body mechanical lift) transfer requirements. This deficient practice placed R5 at risk for impaired care due to uncommunicated care needs. Findings Including: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of heart failure, cerebrovascular disease, major depression (major mood disorder), cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. R5's Quarterly Minimum Data Set (MDS) completed 06/21/24 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. The MDS indicated she was dependent on staff for bed mobility, transfers, toileting, dressing, bathing, and personal hygiene. The MDS indicated she was at risk for falls. The MDS noted she had two non-injury and one minor injury fall since her last assessment. R5's Functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 56 residents. The sample included 14 residents with seven residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to ensure safe care practices were followed during staff-assisted care resulting in multiple preventable falls for Resident (R)5. This deficient practice placed R5 at risk for further falls and injuries. Findings Including: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of heart failure, cerebrovascular disease, major depression (major mood disorder), cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. R5's Quarterly Minimum Data Set (MDS) completed 06/21/24 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. The MDS indicated she was dependent on staff for bed mobility, transfers, toileting, dressing, bathing, and personal hygiene. The MDS indicated she was at risk for falls. The MDS noted she had two non-injury and one minor injury…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 56 residents. The sample included 14 residents with two reviewed for bowel and bladder incontinence. Based on record review, observations, and interviews, the facility failed to implement individualized toileting interventions to improve Resident (R)17's bowel and bladder incontinence or prevent worsening based on his incontinence evaluation. This deficient practice placed R17 at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of legal blindness, muscle weakness, stiffness to his right knee, unsteadiness on his feet, and lack of coordination. A review of R17's Quarterly Minimum Data Set (MDS) completed 05/20/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he required partial to moderate assistance with personal hygiene, toileting, and dressing. The MDS indicated his vision was severely impaired. The MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety for the 58 residents who resided in the facility and received their meals from the facility kitchen , when the facility kitchen failed to ensure clean and sanitary food prep areas, failed to dispose of expired food items, and had expired Parts Per Million (PPM-sanitizer strength test) strips. This placed the 58 residents at risk for foodborne illness. Findings included: - On 06/29/22 at 8:00 AM, observation revealed in the following in the kitchen: The walk-in refrigerator had six uncovered hamburger patties on a tray, 21 hotdogs in an unsealed plastic container, and three uncovered slices of cheese on a plastic container. The floor had clear standing water underneath the air conditioner to the wall underneath the three-well sink, approximately five feet (ft) long, two ft wide, by 1/4 inch (in) deep. The white upright freezer had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 58 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to ensure hazardous chemicals were securely stored. This deficient practice placed four cognitively impaired, independently mobile residents at risk for accidents. Findings included: - On 06/29/22 at 08:00 AM, observation revealed a sink in the dining room, by the kitchen, with a broken lock on the door under the sink. A one-quart sized spray bottle with at least 50 milliliters (ml) of orangish colored fluid, without a label was in the unsecured cabinet. On 06/29/22 at 08:00 AM, Certified Nurse Aide (CNA) M stated she did not know what was in the spray bottle and verified it should be thrown away. On 06/29/22 at 08:12 AM, observation revealed the 100 hall shower room unlocked and a one-quart sized spray bottle of yellowish liquid with a label stating C-diff solution tablets, Keep Out of Reach of Children, hazardous to humans and animals. unsecured. On 06/29/22 at 08:12 AM, Certified Nurse Aide (CNA) M verified the shower room door should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to provide an accurate reconciliation of controlled drugs at the end of daily work shifts. This placed residents at risk for misappropriation of medications by staff. Findings included: - On 06/29/22 at 08:02 AM, observation on the 100-hall medication cart revealed staff counted and signed the Controlled Drug Record flow sheet for one work shift on 06/01/22, 06/08/22 and 06/11/22 (three times out of a possible 58 work shifts). On 06/29/22 at 08:15 AM, observation on the 200-hall medication cart revealed staff counted and signed the Controlled Drug Record flow sheet for one work shift on 06/02/22, 06/11/22, 06/13/22, 06/23/22 and 06/29/22 (five times out of a possible 58 work shifts). On 06/22/22 at 08:15 AM, Licensed Nurse (LN) H stated two staff should count the narcotic drugs every shift and sign the Controlled Drug Record flow sheet to verify the narcotic count was accurate. On 07/06/22 at 08:44 AM, Administrative Nurse D stated two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 58 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to notify the Director of Nursing (DON), medical director, or physician of recommendations for a 14 day stop date or physician's rationale for extended use with a stop date for as needed (PRN) psychotropic medications (medications used to treat mental illness, moods, behaviors) for one sampled resident, Resident (R) 43. This placed the resident at risk for unnecessary psychotropic medications and adverse side effects. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R43 had diagnoses of end-stage renal disease (medical condition in which a person's kidneys cease functioning ), Parkinson's Disease (disorder of the central nervous system that affects movement and often includes tremors, stiffness, rigidity), major depression (mental health disorder characterized by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 58 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use with a stop date for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for one sampled resident, Residents (R) 43. This placed the residents at risk for unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R43 had diagnoses of end-stage renal disease (medical condition in which a person's kidneys cease functioning ), Parkinson's Disease (disorder of the central nervous system that affects movement and often includes tremors, stiffness, rigidity), major depression (mental health disorder characterized by persistent depressed mood, causing significant impairment of daily life), and anxiety (mental health disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.